When women think about hormones, estrogen and progesterone usually get most of the attention.

But women make testosterone too.

And although women have much lower testosterone levels than men, testosterone is still an important part of female physiology throughout adulthood.

The conversation around testosterone for women, however, has become unnecessarily polarized.

On one side, women are told:

“Testosterone is a male hormone. Women don’t need it.”

On the other:

“Testosterone will fix your energy, weight, muscle, mood, brain fog, and libido.”

Neither tells the whole story.

The reality is more nuanced—and much more interesting.

Women can absolutely experience meaningful changes after starting testosterone. At the same time, the research on female testosterone therapy is far less extensive than the research on estrogen, and some of the benefits women report clinically have not yet been adequately studied.

So let’s separate what we know, what women commonly report, and what we’re still learning.

Yes, Women Naturally Make Testosterone

Testosterone isn’t exclusively a male hormone.

Women produce androgens through the ovaries and adrenal glands, as well as through conversion of androgen precursors in other tissues.

Testosterone can also be converted into estradiol through the aromatase enzyme or into the more potent androgen dihydrotestosterone (DHT).

Testosterone levels generally decline across adulthood, but there is an important difference between testosterone and estrogen.

Testosterone does not suddenly disappear when a woman reaches menopause.

The dramatic hormonal change of menopause primarily involves ovarian estrogen production declining and ovulation—and therefore cyclical progesterone production—ending.

Testosterone follows a more gradual trajectory associated with aging and other physiologic factors.

That means menopause does not automatically equal “testosterone deficiency.”

But it also doesn’t mean testosterone becomes irrelevant.

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What Does Testosterone Actually Do in Women?

Androgen receptors are found throughout the female body.

Testosterone participates in normal female physiology involving sexual function and other tissues and systems.

But there is an important distinction:

Knowing that testosterone has a biological role in a tissue does not automatically prove that giving additional testosterone will improve the function of that tissue.

That’s where we have to separate physiology from treatment evidence.

And it’s also where the limitations of female hormone research become important.

Testosterone and Libido: Where the Evidence Is Strongest

The best-established clinical benefit of testosterone therapy in women is its effect on sexual desire and sexual function.

Randomized controlled trials have shown that physiologically dosed systemic testosterone can improve sexual desire, arousal, orgasmic function, pleasure, sexual responsiveness, and sexual distress in appropriately selected postmenopausal women with hypoactive sexual desire disorder (HSDD).

HSDD isn’t simply:

“I don’t want sex as often as I used to.”

It refers to persistent or recurrent low sexual desire associated with meaningful personal distress.

And libido is complicated.

Low desire can also be influenced by:

vaginal dryness
painful intercourse
estrogen deficiency
medications
poor sleep
stress
depression or anxiety
relationship factors
chronic illness
body image
fatigue
other sexual-health concerns

That’s why testosterone shouldn’t be prescribed based solely on a testosterone lab result.

Is HSDD the Only Thing Testosterone Can Help?

This is where the conversation needs more nuance.

Major international consensus guidelines currently describe HSDD in postmenopausal women as the only evidence-based indication for systemic testosterone therapy in women.

But what does evidence-based indication actually mean?

It means this is the clinical use for which we currently have enough randomized controlled trial evidence to support a formal recommendation.

It does not prove that sexual desire is the only aspect of a woman’s health that can possibly respond to testosterone.

Those are two very different statements.

In clinical practice, some women using testosterone report improvements beyond libido, including changes in:

energy or vitality
motivation
overall sense of well-being
exercise performance or recovery
strength
body composition
mood
concentration or mental clarity

Those experiences shouldn’t automatically be dismissed.

At the same time, we shouldn’t promise these outcomes as established benefits when clinical trials have not consistently demonstrated them.

“We don’t yet have strong evidence” is not necessarily the same thing as “this cannot happen.”

Sometimes it means exactly what it says:

We need better research.

The international consensus statement itself calls for additional adequately powered trials examining testosterone’s effects on musculoskeletal health, body composition, cognition, and longer-term outcomes.

What About Testosterone and Energy?

This is one of the most common things women ask me about.

Some women describe a noticeable improvement in energy or vitality after starting testosterone.

Others don’t notice much difference.

Current controlled trials have not established testosterone as a treatment specifically for fatigue or low energy.

And fatigue during perimenopause and menopause can have many possible contributors, including:

disrupted sleep
hot flashes and night sweats
iron deficiency
thyroid dysfunction
inadequate nutrition
medications
sleep apnea
metabolic dysfunction
chronic illness
stress and mood disorders

So I don’t assume:

fatigue = low testosterone.

But there’s another side to this.

If a woman is receiving appropriately monitored testosterone and tells me that her energy, motivation, or vitality has significantly improved, I don’t think that experience should simply be dismissed because fatigue wasn’t the primary endpoint of the major testosterone trials.

It becomes part of her individual clinical response.

That’s different from promising every woman that testosterone will give her more energy.

What About Mood, Motivation, and Brain Fog?

Some women report feeling mentally sharper, more motivated, or simply more like themselves after starting testosterone.

This is an area where patient experience and the published evidence don’t always line up neatly.

Current randomized trials have not demonstrated consistent improvements in cognition or depressed mood, and available evidence does not establish testosterone as a treatment for brain fog, depression, or cognitive decline.

That means I would not tell a woman:

“Testosterone will fix your brain fog.”

But I also wouldn’t tell a woman who experiences a meaningful improvement in concentration or motivation after starting testosterone that the improvement couldn’t possibly be related.

Both ideas can coexist:

The benefit has not been adequately established in clinical trials.

And:

Individual women may report experiencing it.

Good medicine should be able to hold both concepts at the same time.

What About Testosterone, Muscle, and Strength?

This is another interesting area.

Testosterone clearly interacts with muscle physiology.

That makes it tempting to assume that testosterone therapy automatically increases muscle mass and strength in women.

But studies of physiologically dosed testosterone in women have not consistently demonstrated significant improvements in lean body mass, total body fat, or muscle strength.

There are also important limitations to the research: relatively few studies have evaluated musculoskeletal outcomes, participant numbers have been small, and many participants were also using estrogen.

So again, the correct conclusion isn’t necessarily:

“Testosterone has nothing to do with muscle in women.”

It’s:

“We don’t yet have strong clinical-trial evidence showing that physiologic testosterone therapy reliably improves muscle mass or strength in women.”

Those are very different statements.

For women in midlife, resistance training, adequate protein, sufficient nutrition, recovery, sleep, and treatment of relevant medical conditions remain foundational for preserving muscle.

Testosterone isn’t a substitute for those things.

Does Testosterone Help With Belly Fat or Weight Loss?

Testosterone shouldn’t be viewed as a weight-loss medication.

Midlife body composition is influenced by many factors:

aging
estrogen changes
muscle mass
insulin sensitivity
nutrition
physical activity
sleep
stress
medications
genetics

Some women report changes in body composition after starting testosterone.

But physiologic testosterone therapy has not been proven to produce reliable weight loss or significant reductions in body fat in women.

And importantly:

The goal should never be to keep increasing testosterone until weight comes off or muscle appears.

That can push testosterone exposure beyond the normal female physiologic range and increase the risk of androgenic side effects.

Can a Testosterone Blood Test Tell You Whether You Need Testosterone?

Not by itself.

This is one of the most important things to understand.

There is no universally established testosterone cutoff that diagnoses “testosterone deficiency syndrome” in women.

And a testosterone level does not diagnose HSDD.

A woman can have a testosterone result at the lower end of the laboratory range and feel completely well.

Another woman can experience significant symptoms without having an unusually low testosterone concentration.

The international consensus statement specifically advises that a total testosterone concentration should not be used to diagnose HSDD.

So why test testosterone?

Testing can still provide useful clinical context, particularly before and during treatment.

The lab is one piece of the picture—not the entire picture.

Symptoms Matter. Labs Matter. Neither Should Exist in Isolation.

I don’t like either extreme:

“Your lab is low, therefore you need testosterone.”

“Your lab is technically normal, therefore testosterone can’t possibly be relevant.”

Hormone care is more nuanced than that.

I want to understand:

What changed?

When did it change?

What symptoms are most disruptive?

What is happening with estrogen and progesterone?

What medications is she taking?

How is she sleeping?

Could thyroid dysfunction, iron deficiency, metabolic dysfunction, vaginal discomfort, or another condition be contributing?

And if testosterone is used:

Does she actually feel better?

That clinical context matters.

How Is Testosterone Given to Women?

Most of the evidence supporting testosterone therapy in women involves transdermal testosterone.

One challenge in the United States is that there is no FDA-approved systemic testosterone product specifically formulated for women.

As a result, testosterone prescribing for women is generally off-label.

Expert guidelines favor dosing that keeps testosterone exposure within the normal physiologic range for premenopausal women rather than trying to create supraphysiologic levels.

Because women require much smaller doses than men, dosing and monitoring matter.

What About Compounded Testosterone?

Compounded testosterone is commonly encountered in U.S. hormone practices, particularly because there isn’t an FDA-approved female testosterone product.

However, patients should understand the evidence and regulatory distinction.

International consensus recommendations and ISSWSH guidelines generally prefer approved standardized formulations when suitable options are available and recommend against compounded testosterone because compounded preparations do not have the same evidence for efficacy, safety, dose consistency, and regulatory oversight.

In the United States, however, the absence of a testosterone formulation specifically approved for women creates a practical challenge. The accurate dosing is not possible with the current FDA-approved (only for men) gel.

That’s something worth discussing openly rather than pretending it doesn’t exist.

What About Testosterone Pellets?

Pellets are also widely marketed to women.

The concern isn’t simply that they’re testosterone.

It’s the dose, pharmacokinetics, reversibility, and ability to adjust treatment.

Once a pellet is inserted, it can’t easily be removed or quickly adjusted if the dose turns out to be excessive.

For me, one advantage of adjustable therapy is simple:

If a woman’s dose isn’t right, I want to be able to change it.

What Are the Side Effects of Testosterone in Women?

Testosterone isn’t risk-free.

Potential androgenic side effects can include:

acne
oily skin
increased facial or body hair
scalp hair changes in susceptible women

At physiologic female doses, randomized trials have primarily found mild increases in acne and facial/body hair. The consensus evidence did not show clitoromegaly or voice change with physiologic dosing in the studied populations.

But excessive androgen exposure is a different situation.

Supraphysiologic testosterone can increase the risk of more significant androgenic effects, which is another reason that more testosterone isn’t automatically better.

Long-term safety is also an area where we still need better data. Existing trials have generally been relatively short and often excluded women at higher cardiometabolic risk.

How Should Testosterone Be Monitored?

Monitoring isn’t about chasing the highest number a woman can tolerate.

The questions are:

Is she experiencing a meaningful benefit?

Are there androgenic side effects?

Are testosterone concentrations remaining within a physiologic female range?

ISSWSH recommends obtaining total testosterone before treatment and also assessing SHBG. Testosterone should then be rechecked after starting treatment and after dose adjustments to ensure excessive exposure isn’t occurring.

The guideline suggests checking total testosterone approximately 3–6 weeks after initiation, with repeat testing within about six weeks after a dose increase.

But the purpose of monitoring isn’t to titrate toward a magical “optimal testosterone” number.

It’s primarily to prevent excessive exposure while also following the woman’s clinical response.

More Testosterone Is Not Better

This may be the most important point in the article.

If testosterone is appropriate, the goal isn’t to create male testosterone levels in a female body.

A higher testosterone concentration does not automatically mean:

more libido

more energy

more confidence

more muscle

faster weight loss

better aging

At some point, higher exposure may simply mean more side effects.

The goal is not:

“How high can we get your testosterone?”

It’s:

“Are you experiencing a meaningful benefit while keeping treatment safe and physiologic?”

That’s a very different approach.

Testosterone Is Only One Piece of Women’s Hormone Care

A woman may come into my practice saying:

“I think my testosterone is low.”

And sometimes testosterone may ultimately be part of the picture.

But sometimes the evaluation reveals something else—or several things happening simultaneously.

Low libido may partly reflect painful intercourse from vaginal estrogen deficiency.

Poor sleep may be driven by night sweats.

Fatigue may warrant evaluation for thyroid dysfunction, iron deficiency, sleep problems, inadequate nutrition, or another contributor.

Changing body composition may involve estrogen changes, aging, muscle loss, insulin resistance, sleep, nutrition, and activity.

Brain fog may improve when sleep improves.

That’s why I don’t want women’s hormone care reduced to simply replacing whichever hormone looks lowest on a laboratory report.

The better question is:

What is actually contributing to how this woman feels?

So, Is Testosterone Only About Sex?

No—and this is perhaps the biggest takeaway I want women to understand.

Sexual desire is where we currently have the strongest clinical-trial evidence for testosterone therapy.

That doesn’t mean libido is testosterone’s only biological role.

And it doesn’t mean women cannot experience improvements elsewhere.

Some women describe changes in energy, motivation, exercise response, cognition, mood, body composition, or overall well-being after starting testosterone.

Others don’t.

At present, research hasn’t established these as predictable therapeutic benefits of physiologically dosed testosterone.

That uncertainty deserves honesty—but so does women’s lived experience.

“We don’t need to choose between listening to women and practicing evidence-based medicine.

We can do both.”

The Takeaway

Women make testosterone.

Testosterone matters.

And women’s testosterone physiology deserves more serious research than it has historically received.

Right now, the strongest clinical-trial evidence for testosterone therapy involves women with distressing low sexual desire/HSDD, particularly after menopause.

But that doesn’t establish that sexual desire is the only aspect of a woman’s health that can respond to testosterone.

Some women taking testosterone report meaningful improvements in areas such as energy, vitality, motivation, cognition, exercise response, strength, body composition, mood, and overall well-being.

Those experiences shouldn’t be dismissed.

At the same time, they shouldn’t be promised as established benefits when the research hasn’t demonstrated them consistently.

The absence of strong evidence is not always evidence of absence. Sometimes it means we need better studies.

Good testosterone care isn’t about treating every woman with a low lab value.

And it isn’t about restricting the entire conversation to libido.

It’s about understanding her symptoms, considering the complete hormonal and metabolic picture, discussing what we know and what remains uncertain, and carefully monitoring her individual response when treatment is appropriate.

Because ultimately, the goal isn’t to create a perfect testosterone number.

The goal is to help a woman feel better while using hormones thoughtfully, safely, and with an honest understanding of the evidence.

Wondering whether testosterone is part of the picture?

If changes in libido, energy, or other hormone symptoms are affecting how you feel, start with a personalized evaluation of your symptoms, hormone history, relevant labs, and treatment options.

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Zhanna Tarjeft, FNP-BC, FMCP-M provides personalized hormone and functional medicine care for women and men, with a focus on hormone health, thyroid function, digestive health, metabolism, and nutrient optimization.

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